Client initial assessment

Mode of delivery: [Specify whether the consultation was via Telehealth video, telephone, or in-person. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Location: [Specify client's location - home, workplace, vehicle, other location. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Consent form completed: [Yes / No] AI consent: [Yes / No] Referral: [Client referred by: GP with MHCP / DVA referral / Redicase / self-referred / other referral. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] General introduction and history: [Provide brief overview of any mental health history, stigma or therapy concerns, current issues or diagnosis. Write in full sentence format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Mental Status Examination: [Specify how client presented in each category of the mental status examination Appearance: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Behaviour: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Speech: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Language: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Mood and Affect: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Thought Content: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Perception: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Cognition: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Insight and Judgement: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Session content: [Briefly describe the relevant content discussed during the session. Write in full sentence format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Biological/Medical/Physical issues: [Note any biological, medical, physical issues or sleep quality relevant to the client. Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Psychological Issues: Symptoms [List any psychological issues the client is currently experiencing. Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Current Stressors: [Identify current stressors affecting the client. Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Other: Family history/structure: [Specify Number of Siblings? / Birth order? / Biological? / Adopted? / Alcoholism? / Domestic Violence? / Parents still together? / Stepfather? / Stepmother? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Family history of mental health issues: [Specify any known history, diagnosis or observations of family or extended family members. Write in full sentence format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Relationship status: [Single / Married / Separated / Defacto / Divorced / Widow / Widower / Partner (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Children: [Number of children? Sex / Ages of children? How often does the client see or contact children if separated? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Occupation: [Current occupation? / Unemployed? / Training? / Skills? / Qualifications? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Financial situation / Income: [Adequate? / Comfortable / Wealthy / Limited income / Government allowance / DSP / Source of stress? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Sports / Exercise: [History / Regularity / type of sport / exercise / current engagement? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Interests / Hobbies / other activities: [History / Regularity / type of hobby or interest / Current engagement? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Social: [Friends / Colleagues / Family / Extended family / Outings / Gatherings / Social Activities: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Sexuality: [Heterosexual / Homosexual / Bisexual / Other / Issues? / Sexually active? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Religion: [Non-religious / Spiritual / Buddhist / Atheist / Catholic / Christian / Other? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Psychiatric History: [Previous diagnosis / treatment / medications? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Forensic history: [History or current forensic / criminal / legal / police related issues? Current charges? Current court orders? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Sleep: [Average Number of hours in 24-hour period? Onset insomnia / Middle insomnia? Nightmares or disturbing dreams experienced? Sleep medications prescribed? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Appetite: [Food intake and appetite? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Substances: [Drugs / Alcohol / Tobacco / Caffeine: Amount / frequency? History? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Medications: [Current psychiatric medications? Other medications which affect client? Non-prescription medications / vitamin regime (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Trauma / Abuse / Loss / Neglect: [Childhood or adult experiences of trauma, abuse, loss, neglect? Write in full sentence format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Previous Self-harm / suicide attempt: [Previous suicide attempts or episodes of self-harm? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Current Self-harm / suicidal ideation: [Current self-harm or suicidal ideation / plan / intent / means? Risk due to vulnerability - psychosis / dementia / Acquired brain injury / substance use / residing in a remote area / aged in their 50’s / recent depressive episodes / history of self-harm / anxiety disorder / relationship problems / family disruption through separation or divorce / legal problems / harmful substance use / death of a family member / other major stressors Risk to children? Risk to others? Access to firearms or weapons? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Future Orientation: [Outlook on career / job / relationship / family / personal goals / Lifespan? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Overall Risk: [Unless otherwise specified, write "Future oriented", "Adequately supported", "No recent suicidal ideation" in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [· Self-harm risk = Low / Medium / High (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [· Suicide risk = Low / Medium / High (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [· Risk of harm to others = Low / Medium / High (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Safety Plan: [Who would client contact if feeling suicidal? Friend / Family Member / Neighbour / Doctor / Psychologist / Hospital / Emergency Services / Lifeline What are they prepared to do to maintain safety? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Case Formulation: [Pre-disposing Factors: Biological: Chromosomal abnormalities / family history of disease / low intelligence / medical illness? Others? Psychological: Mental illness / Low self-esteem / External locus of control / Difficult personality traits / neuroticism / impulsivity? Others? Social: Social disadvantage / Domestic Violence / Family Disorganisation / Neglectful parenting? Others? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Precipitating Factors: Biological: Injury / New diagnosis / Substance or alcohol use / Pregnancy or hormonal changes? Others? Psychological: Acute life stress / Bereavement / Transition period / Unconscious repetition of early relationship patterns? Others? Social: Bullying / Financial Stressors / Loss of friendships / Unemployment? Others? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Perpetuating Factors: Biological: Poor sleep / Learning disorder / Chronic pain / Effectiveness of medication or treatment? Others? Psychological: Low self-efficacy / Maladaptive coping mechanisms / Cognitive distortions / Poor defence mechanisms? Others? Social: Cultural Insensitivity / Triangulation / Marital distress / Poor social support network? Others? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Protective Factors: Biological: Good physical health / High IQ / Good temperament / No substance or alcohol use? Commenced rehabilitation or physiotherapy? Others? Psychological: High self-esteem / Positive personality traits / Internal locus of control / Adaptive coping mechanisms / Clear communication / Willingness towards help seeking / Maintains daily routine / Resilience / Inner strength / Prior knowledge of coping strategies / Engagement in coping strategies? Others? Social: Good co-ordination among professionals / Good social network support / Low family stress / High socioeconomic status / Connection with extended family / Close and supportive friends / Assertive / Confident / Satisfactory employment / Regular income / Identified hobbies / Identified interests / Identified structured activities Others? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Supports: [Family members / Extended family / Doctor / GP / Hospital / Psychologist / Friends / Neighbours / Others? Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Triggers: [Aggression / High stimulus environments / Loud noises / Odours / Anniversaries / Locations / others? Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Current coping strategies: [Spending time with children or grandchildren / Watching television / Quiet, relaxing activities / Walking the dog / Breathing exercises / Partner support / Visiting friends / Mindfulness / Meditation / Journalling / Hobbies / Exercise / Sports / Colouring / Relaxation / Avoidance / Isolation? Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Overall Impression: [Client’s resilience, insight, family or other supports, treatment goals identified and likely response to treatment? Write in full sentence format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Current signs / symptoms: Depression: [Isolation / Social Avoidance / Negative rumination / Hopelessness / Helplessness / Low Mood / Loss of interest in activities / Weight Loss / Diminished Appetite / Sleep Disruption / Restlessness / Low Energy / Feeling Worthless / Diminished Concentration / Suicidal Ideation / Functional Impairment? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Anxiety: [Excessive Worry most days / Difficult to control worry / Restlessness / Fatigue / Difficulty Concentrating / Irritability / Muscle Tension / Sleep Disturbance / Functional Impairment? (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Diagnosis: [GP diagnosis / assessment: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Psychologist diagnosis: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [ICD-11: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [DSM-5: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Differential diagnosis: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Interventions: [Detail any interventions provided during the session. Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Plan: [Outline relevant therapy, intervention, treatment or course of action for future sessions which may include Psychoeducation / Breathing and relaxation techniques / Behavioural activation / Graded exposure / Strength-building / Reassurance / Supportive counselling / Cognitive Behavioural Therapy / Acceptance and Commitment Therapy / Motivational interviewing / Schema therapy / on-referral / Other? Write in list format if mentioned in the session or added in the context (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Client Treatment Goals: [Detail any specific treatment goals to be achieved through therapy. Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Homework: [Assign any tasks or activities for the client to complete before the next session. Write in list format. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Further Appointments: [Number of weeks (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Follow up: [List all the above categories or titles that remain unanswered and are for follow up (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)